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敗血症(sepsis)與衍伸的名詞

WCH | 2021-03-23 19:04:42 | 巴幣 2 | 人氣 454

對於敗血症(sepsis),有另外的名詞包含:
  • 菌血症(bacteremia)
  • qSOFA(快速相繼器官衰竭評估, quick Sequential Organ Failure Assessment)
  • SOFA(相繼器官衰竭評估, Sequential Organ Failure Assessment)
  • SIRS(全身炎症反應綜合症, Systemic inflammatory response syndrome)
這些名詞彼此多少有相關,但定義又是如何?查了uptodate後稍微整理了一下。

首先是敗血症sepsis的定義,uptodate是這樣寫的:
  • A 2016 SCCM/ESICM task force has defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection (因為宿主對於感染的失衡反應,而導致足具生命威脅的器官失能)
  • Sepsis exists on a continuum of severity ranging from infection and bacteremia to sepsis and septic shock, which can lead to multiple organ dysfunction syndrome (MODS) and death. (敗血症嚴重程度可以初始感染和菌血症,到造成多重器官失能症候群以及死亡)
所以換言之,敗血症一開始是因為感染和菌血症所造成。菌血症嚴重到宿主對感染無法防禦,就會演變成敗血症。

但至於qSOFA和SOFA兩個評分對於sepsis有甚麼關聯?uptodate是這樣解釋的:
  • Identification of early sepsis (qSOFA, NEWS) — Societal guidelines place emphasis on the early identification of infected patients who may go on to develop sepsis as a way to decrease sepsis-associated mortality.
  • Sepsis—Predictive scores (SOFA, systemic inflammatory response syndrome [SIRS], and logistic Organ Dysfunction System [LODS]) were compared for their ability to predict mortality.
  • Importantly, the SOFA score is an organ dysfunction score. It is not diagnostic of sepsis nor does it identify those whose organ dysfunction is truly due to infection but rather helps identify patients who potentially have a high risk of dying from infection.
解釋起來,就是qSOFA適用在早期敗血症的辨識。換言之今天有個病人有感染的跡象,同時也符合qSOFA,那他就有可能有早期敗血症。這時候我們就需要立即給予抗生素、額外加抽血以及退燒治療。

▲這裡可以看到qSOFA只有評估血壓、呼吸頻率和意識狀態改變。沒有考慮到器官衰竭的問題。

而SOFA則是適用於對於敗血症病患死亡率的預測。注意的是SOFA不是用在「診斷」,僅僅是預測病人死亡率高不高。白話一點,SOFA就是在看「病人的器官爛得如何了?」越爛的自然是越容易死掉了。

▲SOFA只有評估器官損壞程度,所以無法診斷敗血症因為無法得知器官是怎麼損壞的。

同時uptodate也有提到現在不太使用「嚴重敗血症severe sepsis」這個名詞,這個名詞過去用來形容敗血症嚴重到全身血液灌流量低和器官衰竭。

而SIRS(全身炎症反應綜合症, Systemic inflammatory response syndrome)又是甚麼呢?SIRS過去被用來形容sepsis所表現的症狀。但現在已經跟sepsis沒什麼關係了。uptodate有這麼一段:
  • The use of systemic inflammatory response syndrome (SIRS) criteria to identify those with sepsis has fallen out of favor since it is considered by many experts that SIRS criteria are present in many hospitalized patients who do not develop infection, and their ability to predict death is poor when compared with other scores such as the SOFA score. SIRS已經不用來辨識敗血症患者,因為一來有SIRS表現的病患往往沒有感染的跡象,二來SIRS用在敗血症病患死亡的評估上也不如SOFA。
  • SIRS is considered a clinical syndrome that is a form of dysregulated inflammation. It was previously defined as two or more abnormalities in temperature, heart rate, respiration, or white blood cell count.  SIRS用來形容有失平衡的發炎反應所表現的臨床症候群,過去的定義是體溫異常、心跳異常、呼吸異常或白血球數量異常中有兩項符合。
  • SIRS may occur in several conditions related, or not, to infection. Noninfectious conditions classically associated with SIRS include autoimmune disorders, pancreatitis, vasculitis, thromboembolism, burns, or surgery. SIRS在有無感染的病患上都可能遇到,非感染的原因可能是免疫疾病、胰臟炎、血管炎、血栓、燒燙燒或是手術所造成。
總之,由於既沒有qSOFA的特異性,又沒有SOFA的預測功能,SIRS已經不單單用在敗血症上面了。

總結就是:

菌血症
↓宿主無法防禦得了感染
早期敗血症←用qSOFA辨識出來
敗血症←用SOFA預測死亡率

SIRS:和敗血症沒這麼有關

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